Towards a structure of the Knowledge Domain for

Augmented Surgery with an ontological approach

MD. Banihachemi Jean-JacquesUrgences, Service de Chirurgie Orthopédique et de traumatologie du SportHôpital Sud – C.H.U. de GrenobleAvenue de KimberleyB.P. 33838434 Echirolles Cedexjjbanihachemi@chu-grenoble.fr

Buffalo Nov.24.2008

SUMMARY

• Presentation

• Work

• Conclusion

LES ALPES

HOPITAL SUD

• Hôpital Universitaire de Grenoble / France

• UJF, a university open to the world and society

• TIMC-IMAG Laboratory : (Techniques for biomedical engineering and complexity management – informatics, mathematics and applications – Grenoble )

Why This Subject

• Emergency Doctor : Cross view of all the medical specialties

• New specialty : – SYmu : Systéme multimedia des urgences:

(WO/2005/059802) SYSTEM AND METHOD FOR PROCESSING INFORMATION RELATING TO MEDICAL HOSPITAL CONSULTATIONS

– Master : Robot-Based Tele-Echography II - A Comparative Study

The aim of this clinical trial is to evaluate the concordance of diagnosis of injuries in thoracoabdominal trauma using two different echographic methods. The first method is a robot-based tele-echography performed by radiologists in a remote location. The second is bedside echography performed by emergency physicians according to the FAST (Focussed Assessment by Sonography of Trauma) examination.

•  GMCAO - (J. Troccaz): Biomechanical modelling, image processing, data fusion and robotics for computer-assisted medical interventions.

•  ThEMAS - (J.L. Bosson) : Epidemiology and clinical research methodology

•  OSIRIS- (M. Simonet): Ontologies, Knowledge and Data: from Modelling to Representation and Exploitation. Application to Intelligent Information Systems in the Health domain

• CAMI Computer Assisted Medical Interventions

• The ultimate objective of the Computer-Aided Medical Interventions (CAMI) research group is clinical: the purpose is to assist the physician or surgeon in the successful execution of diagnostic or therapeutic gestures by minimizing invasiveness whilst improving accuracy

THE PROBLEM

• Augmented Surgery – Around for more than 25 years– Examples

• Orthopilot (B-Braun-Aesculap)

• CT-Free Vector Vision ( BrainLAB)

• Stryker Knee Trac

• Navitrack (Zimmer)

• FluoroKnee System (Smith et Nephew et Medtronic)

Evaluation of quality of existing & new devices Major Challenge

• What is Quality?– General Medical Field : World Health Organization : W.H.O.

• garantir à chaque patient l’assortiment d’actes diagnostiques et thérapeutiques lui assurant le meilleur résultat en termes de santé, conformément à l’état de la science médicale, au meilleur coût pour le meilleur résultat, au moindre risque iatrogénique, pour sa plus grande satisfaction en termes de procédures et de contacts humains à l’intérieur du système de soins

– Pharmacology : AFSSAPS (French National Authority for Health)• Expected Medical Service (EMS)• Delivered Medical Service (DMS)

– Augmented Surgery• EMS: what is EMS in this context?• DMS: what is DMS in this context?• Other notions

Quality in Augmented Surgery

• EMS : To be defined

• DMS : To be defined

EMS and DMS rely on various notions: – Inventory of notions related to Quality– Structuring

Final Objective : Build an Information System for the actual Evaluation of EMS and DMS.

Conceptual Structuring of the Domain

• Ontological approach– Identify Concepts & Relations

related to Quality in Augmented Surgery• Name • Define• Structure

– Conceptual structuring ~ Conceptual Schema, Terminology, Ontology

• Objective: Information System for Quality Evaluation– Conceptual Schema: support to database design– Terminology: standard vocabulary of the domain– Ontology: ultimately …

The TEAM / ACTORS

• Builders team• an emergency doctor with expertise in medical new

technologies Jean-Jacques Banihachemi, MD

• an engineer-doctor with expertise in Augmented Surgery Alexandre Moreau-Gaudry, MD-PhD, head of the

CIC-IT

• a researcher with expertise in the ontological domain Michel Simonet, PhD

• a researcher with expertise in Information System design Ana Simonet, PhD

• Role• Identify and structure concepts • Represent the conceptual structure

THE TEAM / ACTORS

• Users team• Several internationally-published orthopedic surgeons

– SARAGAGLIA. D., MD-PHD– MERLOZ. P., MD-PHD– PLAWESKI. S, MD– ……

• French Public Health doctors who are experts in the domain of Augmented Surgery

– CINQUIN. P., MD-PHD– BOSSON. J-L., MD-PHD– ……

• Role• Validate Concepts and their structuring

MATERIAL

• Expert knowledge

• Bibliographical Texts• valgus osteotomies• anterior cruciate ligament surgery• total knee replacement

• Case report Form• “Medico-economical Evaluation of Surgical

navigation in treating insufficiencies of anterior cruciate ligament surgery of the knee”

• National multi-centric study

Texts from the BibliographyCase Report Form

terms

concepts

terms

terms

concepts

concepts

Expert Knowledge

Organization of concepts by Builder team

Ontological Framework

METHODOLOGY

• Identify Concepts– Acquisition from experts

• Brain storming terms• Grouping equivalent terms concepts

– Extraction from texts• Manual extraction ( Excel file)• Selection and grouping of terms

• Identify Relations– «Structuring» sessions

Fragments of a conceptual structure

MEDICAL DEVICE

PATIENT

EVALUATION

MEDICO-ECONOMIC EVALUATION

SCIENTIFIC EVALUATION

Age, weight, height, gender, BMI

Antecedents

Quality of life

Patient expectations

RESEARCHPATIENT TRAINING

COURSE

Device

dangerous

not dangerousQuality score

Cumberland (CAIT)

Functional scoreNumber of lost working days

Number of days in the hospital

Number of re-hospitalizations

Endoscope robot

Navigation station

(ACL)

Criteria

- individuals / society (political)

- scientific / medico / economic

- cost–benefit ratio

EXPERIENCE

OPERATING PRACTITIONER

Surgeon, neuro-surgeon / orthopedic-surgeon

Radiologist

Emergency Doctor

Gastroenterologist

NON OPERATING PERSONNEL

Anesthetist

Paramedic

TRAINING

for surgeons

Anatomical zones FMA

IS-A IS-A

CE Mark

Prototype/ non prototype Supplier

Purchase price

Observation notebook

Operating procedure

Class

1

2A

2B

3 reanimation – necessity precaution

Software

Evolution

Publications

Prospective trial

Retrospective trial

Functional index

Methodology

Number of user sites

Number of operators

Number of patients operated on

Number of lawsuits

Countries where it is used

GDP

Big Mac Index

indicators

SOCIOLOGY

COMMUNITYDISSEMINATION

METHODOLOGIE D’EVALUATION

Ergonomicsinterface

furtive

Brain Storming

Pathology = surgical indicationGenu varum arthrosique

Surgical treatmentOstéotomie de valgisation

Surgical treatment indicationsA° > 15° => ostéotomie tibiale d’ouverture interne fixée

-Cale phosphate TriCa- Plaque T

A° < 15° => ostéotomie tibiale (ouverture interne) ostéotomie fémorale (ouverture externe)

DMS1 - SurgeonPer-opératoire, à M3182° < Axe mécanique post op < 186°Facilité d’évaluation etc…

2 - PatientScore fonctionnelDouleurAutre… 3 – In terms of Public Health- évaluation médico-économique- f (patients, matériels, etc.…)

4 – Society dimension

Others …

EMS182° < Axe mécanique < 186°Facilité d’évaluation : ergonomie, etc...Formation1 - Surgeon

2 - PatientScore fonctionnel 3 - In terms of Public Health

4 – Society dimension

Mechanical AxisDéfinition axe mécanique-Qu’est-ce que c’est? Définition modalité d’évaluation- Comment?

Clinical trial methodology - Rétrospectif- Comparaison,- Significativité- méthodologie etc.

Pathological Evaluation- Axe mécanique préopératoire

Pre-operative Planning- simuler sur la radiographie l’ouverture souhaitée pour obtenir bon axe mécanique

Quality- Définition des critères- évaluation des différents critères- résultats obtenus-

New technologyDispositif médical

Surgeon

Conceptual fragment

Navigation

Quality

Objective

DefinitionCAMI

System

BackgroundPractical

Anatomy

Robot-assisted surgery

Diminution de l’anisométriePositionnement optimale des tunnels osseux

•Temps consommé (temps additionnel)

•Perception

•Raisonnement

•Action

•Détermination objective de la laxité et son importance

•Positionnement le plus isométrique du transplant

•Rapprochement de la stabilité originale de l’articulation

•précision

definition

•Mécanique•Ultrasonique•Magnétique ou électromagnétique•optique infra rouge +++

•Grenoble TIMC

•Neuro chirurgie

•ORL

•Chirurgie du genou 1992: 1er Prototype

•Planifier

•réaliser

3 generations

•Robot Doc: prototype industriel

•Visée pédiculaire dans la chirurgie du rachis

•Logiciel applicatif : Navitrack, ototrak, orthopilot, surgetics, surgigate

•Positionnement

•Calibrage et évaluation

•Planification et navigation

•Bone morphing

LCA

Précis fiable

Physiopathologie

•Encombrement

•Cout

Clinique: Lachman + Pivot Shift

Radiographie: Telos

Conceptual Fragment

• Brain Storming• Extraction from Texts

Fragments of a conceptual schema “How to arrive to a conceptual Schema?”

Expert in Information System Design

Top Layer of Conceptual Schema

Pathology

Anatomic Zone

Intervention

Patient

Checkup

concerns

recommended forCase 1,1

0,*

Place Team1,11,*

1,*

1,* Medical Device0,*

Usedfor

Uses

EMS

TOP LAYER

1,1

RESULTS

• Three major concepts were identified and support our modelization  – Medical Device – Intervention– Case

• EMS : Linked to the Medical Device • DMS :

– relates to experience with users– evaluated a posteriori, possibly over a long period– refers to several elementary ontology fragments (FMA, ontology of Medical Devices, …)

• Top layer of a conceptual schema (next slide)

Conceptual diagram of an Information systemPlace of intervention Medical Device

Pathology

idstartDateSymptomshandicaps

Intervention

datefuncCheckupBeforefuncCheckupAfternoDaysHospBeforenoDaysHospAfter

EMS

DMS

Patient Checkup(Post-operative)

painFunctional ScoreSubstitution Criteria….

Patientnum

lastNamefirstNamebirthDateaddress

Anatomic ZoneFMA

Observation Start Date

Patient Checkup (Quantified, Preoperative)

painFunctional ScoreSubstitution Criteria….

Team

Members

Surgeon NURSE

LocTeam

SURGEON NURSE?

0,1

1,* 1,*

0,1

1

0,*

0,*

0,*

1,1

1*

1,1

0,*

1,1

1,*

myPat

myIlls

myCode

1,1

1,1

1,1

0,11,1

1,1

0,*

1,*0,*

0,*1,1

???ADELIUNITCOST

1,1

UNITCOST

Physical therapist follow-up

Unit Cost

Phys.Ther.

nurse

Thesaurus

CONCLUSION

• The ontological structuration work : Formalize the notion of Expected Medical Service (EMS) and Delivered Medical Service (DMS)

• Key to quality for Augmented Surgery• Ontological framework : a priceless aid • Support for the design of an Information

System

Perspective

• Support – Teaching– Medical research (data)– Medical economics– Patient’s choice

• Standard for Quality in Augmented Surgery• Towards an Ontology of Quality?

– Out of reach of our group alone Ontological material